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Zooming in to CBT components, zooming out to broader outcome: CBT for anxious youth

Denise Bodden, Leonie Kreuze, Maaike Nauta, Rachel de Jong, Vanessa Cobham Speaker

Anxiety-focused cognitive-behavioral therapy (CBT) effectively reduces anxiety in youths. However, there are large differences in CBT programs, with various components and contextual and structural factors, which may be associated with anxiety reduction as well as broader outcome. The current symposium will shine light on CBT components and outcome. First, we will present a taxonomy tool, that we developed to code the various treatment manuals in order to map the presence of CBT components (e.g. exposure, cognitive restructuring, problem solving, modeling, rewards, social skills training), contextual factors (e.g. target group, parental involvement) and structural factors (e.g. group or individual, number of sessions). Fifty-five manuals were coded and interrater reliability proved to be good. Results provide insight into differences and similarities of CBT programs worldwide. The next presentation is a systematic review and meta-analysis of 42 randomized controlled trials (n=3239 anxious youths), showing that CBT favorably affected general functioning, depressive symptoms, and externalizing behaviors, especially when parents were highly involved. These findings are important, since many anxious children present with comorbid problems and poor functioning. The third study explores whether CBT components, contextual and structural factors of the taxonomy were related to CBT outcome. We selected 70 RCTs with anxiety disordered youth, and outcome was related to potential main and interacting effects of the taxonomy factors, using meta-regression and the novel meta-‘classification and regression trees’ (meta-CART). Finally, we will present a study with youth with speech anxiety (n=70, aged 12-15 years), investigating the benefits of adding the components cognitive restructuring or relaxation to exposure in vivo group sessions in a randomized controlled design.

Chair: Maaike Nauta

Discussant: Vanessa Cobham, 4

1. Denise Bodden, 2. Leonie Kreuze, 3. Rachel de Jong, 4. Vanessa Cobham (discussant)

1. University of Utrecht, the Netherlands;
2-3 University of Groningen, the Netherlands;
4. University of Queensland, Australia

Distinguishing components of CBT: the development of a taxonomy tool

Presenter name and affiliations: Denise Bodden, Department of Child and Adolescent Studies, University of Utrecht, the Netherlands

Cognitive behavioural therapy usually consists of different components, is delivered in different contexts and structures. Also in the field of anxiety disorders in youth, CBT programs widely vary. In order to map these differences, we set out to develop a taxonomy tool. The taxonomy tool provides a framework to code the various treatment manuals in order to map the presence of CBT components (e.g. exposure, cognitive restructuring, problem solving, modeling, rewards, social skills training), contextual factors of the treatment (e.g. target group, parental involvement) and structural factors of the treatment (e.g. group or individual, number of sessions). Fifty-five manuals were coded and interrater reliability proved to be satisfactory to good. Results provide insight into differences and similarities of CBT programs worldwide.

Cognitive-behavior therapy for children with anxiety disorders: a meta-analysis of secondary outcomes

Presenter name and affiliations: Leonie Kreuze, Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, the Netherlands

Anxiety-focused cognitive-behavioral therapy (CBT) effectively reduces anxiety in children and adolescents. An important remaining question is to what extent anxiety-focused CBT also affects broader outcome domains. Additionally, it remains unclear whether parental involvement in treatment may have impact on domains other than anxiety. A meta-analysis (nstudies=42, nparticipants=3239) of the effects of CBT and the moderating role of parental involvement was conducted on the following major secondary outcomes: depressive symptoms, externalizing behaviors, general functioning, and social competence. Randomized controlled trials were included when having a waitlist or active control condition, a youth sample (aged<19) with a primary anxiety disorder diagnosis receiving anxiety-focused CBT and reported secondary outcomes. Controlled effect sizes (Cohen’s d) were calculated employing random effect models. CBT had a large effect on general functioning (-1.25[-1.59;0.90], nstudies=17), a small to moderate effect on depressive symptoms (-0.31[-0.41;-0.22], nstudies=31) and a small effect on externalizing behaviors (-0.23[-0.38;-0.09], nstudies=12) from pre-to post-treatment. Effects remained or even further improved at follow-up. Social competence only improved at follow-up (nstudies = 6). Concluding, anxiety-focused CBT has a positive effect on broader outcome domains than just anxiety. Higher parental involvement seemed to have beneficial effects at follow-up, with stronger improvements in general functioning and comorbid symptoms.

Effectiveness of CBT in treating adolescent anxiety, what works for whom, a meta-regression analysis of treatment components, modalities and mode of delivery

Presenter name and affiliations: Maaike Nauta, Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, the Netherlands

Even though we know that CBT is effective as a treatment package in treating anxiety disorders in children and young people, little is known about which (combination of) components of CBT contribute to its effectiveness. This study explores whether contextual and structural characteristics of CBT treatment packages and CBT components (as derived by a taxonomy of CBT protocols ;see first talk of the current symposium) were associated with CBT outcome in child anxiety. We performed a systematic search in the relevant databases, and 68 articles of randomized controlled trails RCTs were selected by two independent reviewers. RCTS comparing CBT as indicated prevention or treatment, to an inactive intervention (e.g. waitlist, no treatment, monitoring) for (sub)clinical symptoms of anxiety in youth, were included. Data extraction was carried out by two independent researchers. The quality of studies was assessed using the ‘Clinical Trials Assessment Measure for Psychological Treatments’ (CTAM) scale and the Cochrane Risk of Bias tool.Cohen’s d was calculated as a measure of effect size for both self- and parent-reported anxiety levels. Treatment outcome was then related to potential main and interacting effects of the structural and contextual factors as well as the CBT components, using meta-regression and the novel meta-‘classification and regression trees’ (meta-CART). Results will show if any of the components, contextual factors, or structural factors, or their combination, were associated with changes in child and parent reported child anxiety symptomatology.

Core Elements of Cognitive Behavioural Therapy in Treating Speech Anxiety in Youth: Facing Fears by Focussing on Behaviour, Body, or Mind?

Presenter name and affiliations: Rachel de Jong, Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, the Netherlands

The most common CBT element in current intervention packages for anxiety in youth is exposure, which is often only applied after providing the child with cognitive restructuring (CR) and relaxation exercises (RE) as preparation for exposure. However, there is hardly empirical evidence for the additional value of CR or RE (Reynolds, Wilson, Austin, & Hooper, 2012). In addition, it is unclear whether the combination of these elements with exposure is counterproductive compared to the use of exposure only. In this study, the effectiveness of these three different types of CBT-elements was evaluated in the treatment of speech/performance anxiety among adolescents. Sixty adolescents aged 12 to 15 years with subclinical or higher levels of the fear of performance/public speaking subtype of social phobia were randomly assigned to one of three conditions: exposure only, exposure + CR, exposure + RE. All adolescents were offered one psycho-education session on anxiety, social phobia and exposure, followed by either four sessions of exposure, or two sessions of either CR or RE and two sessions of exposure. Before and after treatment, speech anxiety was measured, including the different dimensions of anxiety (approach/avoidance behavior, cognitions and bodily tension). Preliminary results will be reported and discussed.